Healthcare Provider Details

I. General information

NPI: 1679197883
Provider Name (Legal Business Name): MISS AMANDA LEE PETHERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 12/03/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15251 S 50TH ST APT 1070
PHOENIX AZ
85044-9110
US

IV. Provider business mailing address

15251 S 50TH ST APT 1070
PHOENIX AZ
85044-9110
US

V. Phone/Fax

Practice location:
  • Phone: 480-294-2831
  • Fax:
Mailing address:
  • Phone: 480-294-2831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: